What has been learned about COVID‐19 vaccine hesitancy in Pakistan: Insights from a narrative review

Abstract Background Vaccine hesitancy is not a new phenomenon to Pakistan. This is evidenced through the slow progress of previous vaccination campaigns and programs against MMR, BCG, and especially polio. This issue continues to persist and is therefore becoming the cause of low COVID‐19 vaccination rates in Pakistan. Aim To provide insights about COVID‐19 vaccine hesitancy among Pakistanis, and its potential harm on public health. Moreover, we aim provide recommendations to counter the factors limiting the COVID‐19 vaccination in Pakistan. Methodology A Boolean search was conducted to find the literature in MEDLINE‐PubMed, Google Scholar, and Clinicaltrials.gov databases up till March 16, 2022. Specific keywords were used which comprised of “SARS‐CoV‐2,” “COVID‐19,” “vaccine hesitancy,” “vaccine acceptance,” “intention to vaccinate,” and “Pakistan,” with use of “OR” and “AND.” Only free full‐text original studies in English language were used to compare and contrast. Results As proven by various studies, COVID‐19 vaccination rates are influenced by multiple factors, including inaccurate beliefs about COVID‐19, hesitancy amongst healthcare workers, uncertainty regarding vaccine's efficacy and fear of side effects. Various conspiracy theories and lower testing rates among others also add up to impose a negative impact on the vaccination rates and public health of Pakistan. This may lead to newer strains of potentially harmful COVID‐19, mental health deterioration, and prolonged lockdowns. Conclusion Vaccine hesitancy is a global public health threat, and its impacts are pronounced in Pakistan. This is reflected in the COVID‐19 pandemic; low vaccination rates in Pakistan may lead to future outbreaks of new, potentially harmful, strains of COVID‐19 which can prolong lockdowns in the country and affect mental health of the population. To improve the current situations, it is imperative for the government, educational institutes, and healthcare systems to develop trust and continually use dialogue, communication, and education to address misconceptions to improve COVID‐19 vaccination in Pakistan.

grief, and other psychiatric disorders, which may have a negative influence on the perspective of the population towards the disease and vaccination as a prevention strategy. 10 As of yet, around 64.5% of the world population has received at least the first dose of COVID-19 vaccine, with approximately 11.29 billion doses administered worldwide. 11 Currently there are seven vaccines approved for usage in Pakistan against COVID-19, including Moderna, Pfizer/BioNTech, Convidicea, Sputnik, Oxford/AstraZeneca, Sinopharm (Beijing), and Sinovac (further information on the vaccines available are provided in Table 1). 20 A booster shot is also recommended due to the concern that efficacy of the vaccine decreases over time, and may prove to become ineffective against a new strain.
Amidst the implementation of vaccination in the country, Pakistan is facing an emerging challenge of public hesitancy against COVID-19 vaccination. Vaccine hesitancy, which is the delay in acceptance or refusal of vaccines despite its availability, 21 is not an uncommon phenomenon in Pakistan, as proven by the slow progress of the campaigns against polio in previous years, which have however shown success recently. 22,23 Considering the sensitive mindset among the population regarding vaccination, any negative convictions against COVID-19 immunizations could affect the progressing endeavors to conclude the widespread and may precipitate the complications and long-term effects associated with the pandemic as discussed above. COVID-19 immunization aversion thus remains an overwhelming challenge against the public wellbeing of Pakistan amid these delicate circumstances. Therefore, this narrative review aims to provide an insight into Pakistan's vaccination drive by comparing findings of different studies, highlighting the perspective of Pakistanis towards COVID-19 vaccination and efforts made by the government in alleviating the pandemic, and its impacts on public health.
Moreover, this review also aims to provide recommendations to counter the low vaccination rates and limit the impacts of it on the public health of Pakistan.

| METHODS
A Boolean search was carried out to find the literature in MEDLINE-PubMed, Google Scholar, and Clinicaltrials.gov databases up till March 16, 2022. We used specific keywords that consisted of "SARS-CoV-2," "COVID-19," "vaccine hesitancy," "vaccine acceptance," "intention to vaccinate," and "Pakistan," with interposition of "OR" and "AND." Full text of all the related articles in English language was retrieved and exported on an excel sheet. The detailed search strategy used is as follows:

| COVID-19 vaccination statistics in Pakistan
The first COVID-19 vaccine in Pakistan was given on February 3, 2021. 24  suggests that only 37.6% of the vaccine hesitant people thought it was effective (details provided in Table 2). 39 Furthermore, many women are hesitant to get vaccinated while pregnant due to the perceived implications of the vaccine on the fetus, although studies have shown that the vaccine is safe during pregnancy, and it is the virus that can lead to harmful pregnancy-related complications. 40,41 These doubts and health concerns show the need for better communication between the government and the general public.

| Inaccurate beliefs about COVID-19
The timely development of COVID-19 vaccines has had a significant impact in reducing the severity of the symptoms and in combating the spread of the virus. 42  are to blame for the public's frivolous attitude towards the disease.
The death rate was low due to underreporting of cases along with fewer testing, and almost 150 countries conducted more COVID tests per million population than Pakistan. 46 The country's younger population was another reason for the low death rate. However, many falsely believed that the low death rate was because many Pakistanis had a stronger immune system in general. 46

| COVID-19 testing
In the wake of the global pandemic, the government of Pakistan along with its healthcare authorities has faced many obstacles in reducing the virus' spread. Hesitancy to COVID-19 testing is among the many reasons. Testing is a key component in understanding the true extent of the pandemic and subsequently coming up with solutions to slow or halt the spread of the disease, as testing can reveal whether flulike symptoms are due to influenza or SARS-CoV-2. 54 Although government centers offered free COVID-19 testing across the country, many people were hesitant to get tested. Fear of needles was also a cause of refusal from 10% of the vaccine hesitant population. 37 Moreover, many were afraid that they would have to self-isolate and could miss work, a luxury which many working-class citizens could not afford. 55 Additionally, many of the virus' symptoms were general like cough, fever, and headache, which made differential diagnosis a challenge and many assumed they just had the seasonal flu and did not get tested. 56 On the contrary, those who did get tested had a 38% chance of being false negative. 57

| Public gatherings
Religious occasions have also contributed to the virus' spread. Ten days before Eid in 2020, lockdowns were eased throughout the country so people can meet their families and spend the joyous occasion with their loved ones. However, the decision backfired as number of daily cases in the second week of June, following the religious holiday of Eid, which is celebrated by a majority of the country. 46

| The gray area
Multiple studies showed that many participants feared the vaccines' side effects, 37 COVID-19 vaccines' long-term health implications, which is fair considering the vaccine only became widely available in 2021. 60 Apart from the vaccine, COVID-19's long-term health implications also require more research. This is essential as many of the surveyed participants were also vaccine hesitant because they did not consider COVID-19 a serious threat to their wellbeing. 38 62 Studies have further indicated that COVID-19 coinfection with current or prior TB disease is associated with less favorable COVID-19 outcomes, such as a two-to three-fold increase in mortality or a 25% relative decrease in recovery. 62 In terms of COVID-19 vaccine hesitancy, lower vaccination rates can have a number of detrimental effects on the ongoingTB crisis across the country as COVID spread may mask TB transmission, which renders previous efforts by the country to control TB ineffective. To combat the spread of the disease, many resources have been redirected, which can be used to improve local healthcare facilities, but the low vaccination rates hamper the progress.

| Effects on public health
Countries seeking to close the immunization gap face an increasing challenge from those who delay or refuse vaccines for themselves or their children. As novel strains of COVID-19 emerge and impose a threat to everyone's health, vaccine hesitancy and refusal put the lives of others, especially the immunocompromised, at risk. 63 To reduce their risk of exposure, these people depend upon the general public to be vaccinated.
Not just COVID-19, but the vaccine may also protect against other immune-deficiency diseases, such as the common flu and colds with overlapping clinical manifestations including cough, fever, fatigue, runny nose, headache, and sore throat. 64,65 Receiving the vaccine would not only protect the people against contracting the disease but will also minimize complications in those who do contract it even after vaccination. 64 Lack of mobility has previously been a major issue among the confined as people kept themselves isolated, ignoring their basic needs. 64 Social isolation, quarantine, and loneliness have been shown to increase the risk of depression and anxiety, negatively affecting public mental health. 66 It is therefore crucial that measures should be taken on a national level to circumvent future barriers, and devise effective strategies for vaccinating a sufficient number of individuals around the world to achieve herd immunity and significantly reduce health disparities. Regulatory Authority, which works together with the Ministry of Information to regulate various media outlets and even has the authority to suspend or cancel these same outlets' licenses. 67 Therefore, the government has the capabilities to censor and punish any news outlets that purposely spread damaging misinformation surrounding COVID-19 and its vaccination. This is essential as many of these same news outlets have had conspiracy theorists televised to the general public stating falsehoods such as that the vaccine is a way for Bill Gates and western countries to make Muslims slaves to the United States along with other extremely outlandish claims. 68 Not only should these news outlets have their license suspended, but those who are responsible for televising such segments should be held accountable and if required, punished, as the misinformation they spread will inevitably lead to fear surrounding the vaccine, thus leading to lower vaccination rates and eventually more cases of COVID-19 culminating into more COVID-19-related deaths. By holding those responsible accountable, it will deter other news outlets from freely spreading false information and will encourage them to put more effort into cross-checking the very same information before televising it. Furthermore, these same stations should employ educated healthcare professionals to speak on the matter as this engagement between them and the general public will women. The same society also found that the vaccine is crucial in preventing a critical COVID-19 infection which is essential for maintaining the health of both the mother and her unborn child. 40,41 The educational institutions, especially those that educate in the medical field, can educate their students in the same way. This will in turn lead to the same students bringing the knowledge home and further educating their family members including those who may be skeptical about the vaccine but may trust their relatives who are in such institutions since it comes from a trusted family member. Lastly, although unfortunate, many people do get their information from social media which is a platform rife with misinformation. 70 Even though it is difficult to limit the spread of this misinformation and to penalize those who do, it is possible to educate the influencers of various social media platforms such that they can share the proper information with their general audience. Even though it is difficult to limit the spread of this misinformation and to penalize those who do, it is possible to educate specific key influencers of various social media platforms such that they can share the proper information with their general audience. It is unreasonable to educate every influencer; however, a task that is more plausible would be to find specific influencers who have a wider agoraphobia may find it difficult to travel to vaccination centers and those with trypanophobia who fear needles will be resistant to taking the vaccine altogether. Trypanophobia is particularly of concern as according to a study, 30% of young adults were affected by it. 50 Therefore it is evident that psychiatrists play an essential role in In other countries many private companies offered discounts and promotions to individuals who received the COVID-19 vaccination. 72 Similarly, it is possible to encourage local companies to do the same here as many people would follow the trend of availing said promotions and spreading the news to those around them, thus encouraging more people to get vaccinated. This would be beneficial to the same companies as more people being vaccinated would lead to less lockdowns resulting in more consumer traffic with corresponding additional sales. Furthermore, the government themselves can also have their social programs make it mandatory for people to get the vaccine to continue receiving benefits for said programs. This would make it necessary for many people to get the vaccine and reduce vaccine hesitancy.

| LIMITATIONS
Our study had some limitations associated which included selection bias as no systematic review or meta-analysis was performed, and the studies included were only used to compare and determine the factors associated with COVID-19 vaccine hesitancy in Pakistan based on their importance. Moreover, like any other narrative review, our study also had a subjective approach with the methodology section and thus the conclusion was also subjective of the authors' interpretation of the sensitivity of the factors.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data are included in the manuscript, Mohammad Yasir Essar had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis."

TRANSPARENCY STATEMENT
The lead author Mohammad Yasir Essar affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.